Thoracotomy Patients Under General Anesthesia: A Comparison on Intra-Operative Anesthetic and Analgesic Requirements, When Combined with Either Epidural Analgesia or Continuous Unilateral Paravertebral Analgesia.

BACKGROUND AND OBJECTIVE: Regional analgesia is effective for post-thoracotomy pain. The primary objective of the study is to compare the intraoperative requirement of isoflurane and fentanyl between general anaesthesia (GA) with epidural analgesia and GA with paravertebral analgesia. METHODS AND MATERIAL: A prospective observational comparative study was conducted on 56 patients undergoing open thoracotomy procedures. The patients were divided into two groups of 28 by assigning the study participants alternatively to each group: Group GAE - received thoracic epidural catheterization with GA, and Group GAP - received ultrasound guided thoracic paravertebral catheterization on the operative side with GA. Intraoperative requirement of isoflurane, fentanyl, postoperative analgesia, stress response, need of rescue analgesics and adverse effects were observed and analysed. RESULTS: 25 patients in each group were included in the data analysis. The intraoperative requirement of isoflurane (32.28 ± 1.88 vs 48.31 ± 4.34 ml; p < 0.0001) and fentanyl (128.87 ± 25.12 vs 157 ± 30.92 µg; p = 0.0009) were significantly less in the GAE group than in the GAP group. VAS scores and need of rescue analgesics and blood glucose levels were not statistically significant during the postoperative period (p > 0.05). The incidence of adverse effects was comparable except for hypotension and urinary retention which were significantly higher in the GAE group. CONCLUSION: GA with epidural analgesia resulted in significant reduction in the intraoperative consumption of isoflurane and fentanyl in comparison to GA with paravertebral analgesia. However, both the techniques were equally effective in the postoperative period.

Intraoperative Transesophageal Echocardiographic Assessment of Aortic Valve Repair in a Child - What to Look for?

ABSTRACT: Aortic valve (AV) repair is the desired surgical treatment option for young patients with aortic regurgitation (AR). It is considered as a class I indication for the surgical treatment of severeAR. The success of an AV repair depends on the detailed intraoperative transesophageal echocardiographic (TEE) examination which should fulfil the information required by the surgeon. The objective of this echo round is to describe the role of intraoperative TEE in systematic evaluation of the AV, before and after repair.

Three-Dimensional transesophageal echocardiographic detection of left ventricular outflow tract obstruction by residual native mitral leaflet following mitral valve replacement in a hypertrophic obstructive cardiomyopathy patient.

Hypertrophic obstructive cardiomyopathy (HOCM), although a worldwide prevalent cardiac disease, it imposes a greater task in the patient management. The association of coronary artery disease with HOCM poses an immense perioperative challenge and it demands an expert transesophageal echocardiography (TEE) examination for guiding the surgery and detailed assessment after surgical correction. We report a case of HOCM with coronary artery disease where the post-cardiopulmonary bypass three-dimensional TEE played a crucial role in exact identification of the mechanism of fixed left ventricular outflow tract obstruction, when the two-dimensional TEE failed to provide adequate information.

Sepsis in the Pediatric Cardiac Intensive Care Unit: An Updated Review.

Sepsis remains among the most common causes of mortality in children with congenital heart disease (CHD). Extensive literature is available regarding managing sepsis in pediatric patients without CHD. Because the cardiovascular pathophysiology of children with CHD differs entirely from their typical peers, the available diagnosis and management recommendations for sepsis cannot be implemented directly in children with CHD. This review discusses the risk factors, etiopathogenesis, available diagnostic tools, resuscitation protocols, and anesthetic management of pediatric patients suffering from various congenital cardiac lesions. Further research should focus on establishing a standard guideline for managing children with CHD with sepsis and septic shock admitted to the intensive care unit.

Bedside Chest Ultrasound in Postoperative Pediatric Cardiac Surgery Patients: Comparison With Bedside Chest Radiography.

OBJECTIVE: The primary objective was to study the degree of agreement between the chest ultrasound (CUS) studies and chest x-ray (CXR) studies in postoperative pediatric cardiac surgical patients regarding the diagnosis of thoracic abnormalities, and also to compare the diagnostic performance of CUS in reference to CXR for the detection of thoracic abnormalities. The secondary objective was to compare the necessity for interventions done on the basis of CUS and CXR findings in the postoperative setting. DESIGN: A prospective observational study. SETTING: At a postoperative pediatric cardiac surgical intensive care unit in a tertiary-care center. PARTICIPANTS: One hundred sixty patients between the age of 2 months to 18 years undergoing elective cardiac surgery for various congenital heart diseases. INTERVENTIONS: After obtaining permission from the institutional ethics committee, 160 pediatric cardiac surgical patients were studied prospectively in the postoperative period. On the day of surgery (postoperative day [POD] 0), bedside CXR was done in the immediate postoperative period. After bedside CXR, CUS examination was performed and then interpreted by the principal investigator. The CXR was interpreted by the surgical team. Provisional diagnosis was made by the principal investigator and surgical team. Any intervention required was decided based on CXR or CUS findings or both. The procedure was repeated in the morning of POD 1. MEASUREMENTS AND MAIN RESULTS: The degree of agreement between CUS studies and CXR studies in detecting abnormalities was evaluated by Cohen's kappa (k) statistics. The diagnostic performance of CUS was compared with that of CXR using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy. Overall, kappa analysis (k) showed substantial agreement between the findings of the CUS and CXR studies (k = 0.749). The diagnostic performance of CUS, as compared with CXR, was found to have a sensitivity of 96.9%, specificity of 84.75%, PPV of 73.4%, NPV of 98.43%, and diagnostic accuracy of 88.44%. In 94 abnormal findings, the interventions were done based on CUS or CXR findings or both. Overall, there was a substantial agreement (k = 0.787) between CUS and CXR regarding the necessity for interventions. CONCLUSIONS: The degree of agreement between CUS and CXR studies was substantial for atelectasis, interstitial edema, and diaphragmatic weakness. The degree of agreement between CUS and CXR studies was almost perfect for pneumothorax and fair for pleural effusion. More CUS studies detected intrathoracic pathologies than CXR studies. The CUS also detected abnormalities earlier than CXR and was found to be useful for the early institution of intervention therapy in patients with interstitial edema and atelectasis. It would be reasonable to conclude that CUS may be considered in some instances as an alternative to CXR.

Clinical outcomes of del nido cardioplegia and st thomas blood cardioplegia in neonatal congenital heart surgery.

OBJECTIVES: Cardioplegia is essential for adequate myocardial protection. There continues to remain ambiguity regarding the ideal cardioplegia for adequate myocardial protection in congenital heart surgery. This study compares clinical outcomes using St Thomas II solution and Del Nido cardioplegia in neonates undergoing cardiac surgery. METHODS: All neonates (<30 days) from 2011 to 2017 who underwent surgery requiring cardioplegic arrest were analyzed retrospectively. We divided the cohort into two groups depending on cardioplegia received, as group A (Blood cardioplegia with St Thomas II solution, n = 56) and group B (Del Nido cardioplegia, n = 48). Various demographic, intraoperative, early postoperative, and discharge variables were analyzed. RESULTS: Two groups were similar in age, gender, pre-operative diagnosis, and risk category. Cardiopulmonary bypass (CPB) time (P = 0.002), aortic cross-clamp (ACC) time (P = 0.018), and the number of doses of cardioplegia (P < 0.001) were significantly lower with Del Nido group. Though vasoactive inotropic score (VIS) (P = 0.036) was high during the first 24 h in the immediate postoperative period in group A, there was no difference in early mortality among both groups (P = 0.749). Both groups did not show significant differences related to various postoperative and discharge variables. CONCLUSION: When compared to St. Thomas solution, the use of Del Nido cardioplegia solution in neonates is associated with a significant decrease in CPB and ACC times and VIS in the first 24 h after surgery. The choice of cardioplegia (St Thomas/Del Nido) in neonates does not affect early mortality and early postoperative clinical outcomes.

Extracardiac Intrapericardial Mass Impersonating as Left Atrial Mass: Echocardiographic Perspectives.

Extracardiac intrapericardial masses arising posterior to left atrium (LA) often mimic an intracardiac LA mass on echocardiography. Although transthoracic echocardiography (TTE) is the primary screening tool to detect any cardiac mass, transesophageal echocardiography (TEE) is proven superior to TTE in delineating the size, morphology, and exact site of origin of LA masses. We report a case, where the preoperative TTE diagnosed an LA mass which was later confirmed to be an extracardiac intrapericardial mass by cardiac magnetic resonance imaging and intraoperative TEE. The mass was compressing the LA, and the timely diagnosis avoided the opening of the LA for mass excision.

Transthoracic intracardiac catheters in perioperative management of pediatric cardiac surgery patients: a single-center experience.

BACKGROUND: Transthoracic intracardiac catheters inserted under direct vision in the pulmonary artery and left atrium during cardiac surgery play major roles in the management of patients with complex congenital heart disease. We aimed to analyze the utility of transthoracic intracardiac catheters in the perioperative management of pediatric cardiac surgery patients and review catheter-related morbidity. METHODS: The computerized register of all pediatric cardiac surgery patients in whom transthoracic intracardiac catheters were inserted from 2012 to 2019 in a tertiary referral center were reviewed. RESULTS: Transthoracic pulmonary artery and left atrial catheters were inserted in 89 and 71 patients, respectively. The most common indications for pulmonary artery and left atrial catheters were total anomalous pulmonary venous connection (52%) and total cavopulmonary connection (58%) respectively. The most common reason for elevated pulmonary artery and left atrial pressure after cardiopulmonary bypass was left ventricular dysfunction. Transthoracic pulmonary artery catheters helped in diagnosing pulmonary hypertensive crisis (29%), surgical decision-making (14%), and ventilator therapy (16%). Left atrial catheters helped in the diagnosis of left ventricular dysfunction (54%). The incidence of morbidity was 8.9% for transthoracic pulmonary artery catheters and 9.8% for left atrial catheters. CONCLUSION: Transthoracic pulmonary artery catheters help in the diagnosis and management of pulmonary hypertensive crisis, for making perioperative surgical decisions, and during ventilator therapy. Transthoracic left atrial catheters help in the diagnosis of left ventricular dysfunction in the perioperative period. The diagnostic and treatment benefits provided by transthoracic intracardiac catheters outweigh the minor adverse events, supporting their continued use in the perioperative period.

Bedside Lung Ultrasound for Postoperative Lung Conditions in Cardiothoracic Intensive Care Unit: Diagnostic Value and Comparison with Bedside Chest Roentgenogram.

BACKGROUND: The postoperative settings in cardiothoracic intensive care unit (ICU) patients pose a certain risk with pulmonary dysfunction causing morbidity and mortality. Lung ultrasound (LUS) has a potential to supplant or replace Chest X-rays (CXR) in these subset of patients, who will require bed side pulmonary pathology diagnosis and interventions. AIMS AND OBJECTIVES: Aim of the study is to compare the diagnosis predicted from LUS to the diagnosis made from routine bedside CXR and to find the degree of agreement in diagnosis made by both modalities in different cardiopulmonary pathologies in ICUs. MATERIALS AND METHODS: Prospective observational study involving 250 postoperative patients, admitted in cardio-thoracic and vascular ICU of a tertiary referral centre. LUS was done in the study patients after the scheduled CXR in the immediate postoperative period and postoperative day one. Findings of pulmonary pathologies by each imaging modality were independently interpreted by two different team of specialist investigators. The findings were evaluated for the degree of agreement between the two imaging modalities using Cohen's kappa statistical test. RESULTS: CXR and LUS imaging showed substantial agreement in the diagnosing cardiopulmonary pathologies (κ = 0.652) in the immediate postoperative period as well as on the postoperative day one (κ = 0.740). For specific cardiopulmonary pathologies, the degree of agreement was moderate for pleural effusion (κ = 0.561), substantial for atelectasis (κ = 0.673) and interstitial edema (κ = 0.707) and perfect for pneumothorax (κ = 0.931). CONCLUSIONS: LUS can effectively replace CXR with reduction in radiation exposure in the immediate postoperative period and also in the follow up period. It can be used as a bedside diagnostic and monitoring tool in postoperative cardiothoracic and ICUs for diagnosing pneumothorax, pleural effusion, atelectasis and interstitial edema.

Ultrasound Imaging of the Inferior Vena Cava to Confirm Correct Guidewire Placement After Femoral Venous Cannulation in Critically Ill Neonates: A Case Report.

Ultrasound-guided femoral venous cannulation is frequently performed in neonates. Identification of femoral vessels under ultrasound navigation is unreliable and time consuming in hemodynamically unstable neonates with feeble femoral arterial pulse. Confirming the guidewire placement in a femoral vein is a crucial step for preventing inadvertent femoral artery dilation, which may be a challenging task in an emergency situation. We describe 2 incidents wherein guidewires placed via femoral veins in neonates were detected in the inferior vena cava on abdominal ultrasound. We advocate abdominal inferior vena cava imaging to confirm the correct placement of a guidewire placed via femoral vein in emergency situations.

Intraoperative Transesophageal and Postoperative Transthoracic Echocardiographic Evaluation of a Mechanical Heart Valve Prosthesis Implanted at Aortic Position.

OBJECTIVE: The aims of this study were to evaluate the intraoperative transesophageal echocardiographic (iTEE) characteristics and Doppler flow profile of aortic Chitra heart valve prosthesis (CHVP) under stable hemodynamic and loading conditions, and to compare and correlate the iTEE data with the postoperative transthoracic echocardiography (TTE) data obtained at 48 hours (TTE1) and 3 months (TTE2) after the surgery. DESIGN: Prospective, observational study. SETTING: University-level tertiary referral hospital. PARTICIPANTS: Forty patients between 18 years and 65 years of age undergoing elective aortic valve replacement (AVR) using CHVP during the period January 2015 to August 2016. INTERVENTIONS: After obtaining permission from institutional ethics committee, 40 patients undergoing elective AVR were studied prospectively. The iTEE examination was performed in the pre-cardiopulmonary bypass (CPB) and post-CPB period in all the study subjects. CHVP was subjected to iTEE two-dimensional (2D) echo, color Doppler, and spectral Doppler evaluation under stable hemodynamic and loading condition in the post-CPB period after the administration of protamine. The CHVP were re-evaluated using TTE in all the patients 48 hours after the surgery (TTE1) and 3 months after the surgery (TTE2). The iTEE and postoperative TTE Doppler values were compared and correlated. MEASUREMENTS AND MAIN RESULTS: The CHVP could be imaged adequately and interrogated with Doppler in all the patients. None of the patients had restriction of occluder mobility or unstable seating of the valve. The intraoperative flow dependent (peak velocity [PV] and mean pressure gradient [MPG]) and less flow dependent (Doppler velocity index, acceleration time, acceleration time/ejection time, effective orifice area [EOA] and indexed EOA) Doppler parameters of CHVP were measured as per the American Society of Echocardiography recommendations. The PV and MPG of CHVP measured by iTEE showed no statistical difference (p > 0.05) and were in limits of agreement when compared with TTE1 and TTE2 data. CONCLUSION: The iTEE features of CHVP were found compliant with the criteria set by the ASE defining normal functioning of an aortic valve prosthesis. The iTEE Doppler parameters obtained under stable loading conditions strongly predicted the postoperative values of Doppler parameters on TTE examination. The iTEE Doppler values can be used as the reference values for the postoperative follow up studies.

Mitral Inflow Obstruction Resulting From a Dilated Coronary Sinus: Role of Intraoperative Transesophageal Echocardiography in Diagnosis and Surgical Repair: A Case Report.

Mitral inflow obstruction caused by dilated coronary sinus is a rare congenital cardiac anomaly that must be differentiated from other causes of left ventricular inflow obstruction such as cor triatriatum, supramitral membrane, and supramitral ridge, because their surgical repair is different. Although preoperative transthoracic echocardiography is the primary imaging modality for diagnosis, intraoperative transesophageal echocardiography has a higher sensitivity and specificity over transthoracic echocardiography in differentiating these lesions. We report 2 cases of supramitral obstruction where the intraoperative transesophageal echocardiography has refined the preoperative diagnosis and changed the course of surgical repair.

Practice guidelines for perioperative transesophageal echocardiography: recommendations of the Indian association of cardiovascular thoracic anesthesiologists.

Transoesophageal Echocardiography (TEE) is now an integral part of practice of cardiac anaesthesiology. Advances in instrumentation and the information that can be obtained from the TEE examination has proceeded at a breath-taking pace since the introduction of this technology in the early 1980s. Recognizing the importance of TEE in the management of surgical patients, the American Societies of Anesthesiologists (ASA) and the Society of Cardiac Anesthesiologists, USA (SCA) published practice guidelines for the clinical application of perioperative TEE in 1996. On a similar pattern, Indian Association of Cardiac Anaesthesiologists (IACTA) has taken the task of putting forth guidelines for transesophageal echocardiography (TEE) to standardize practice across the country. This review assesses the risks and benefits of TEE for several indications or clinical scenarios. The indications for this review were drawn from common applications or anticipated uses as well as current clinical practice guidelines published by various society practicing Cardiac Anaesthesia and cardiology . Based on the input received, it was determined that the most important parts of the TEE examination could be displayed in a set of 20 cross sectional imaging planes. These 20 cross sections would provide also the format for digital acquisition and storage of a comprehensive TEE examination. Because variability exists in the precise anatomic orientation between the heart and the esophagus in individual patients, an attempt was made to provide specific criteria based on identifiable anatomic landmarks to improve the reproducibility and consistency of image acquisition for each of the standard cross sections.